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There’s a problem in our cities: whole neighborhoods are sick. Zip codes are better predictors of health outcomes than biology. And despite the efforts of many, we have failed to build sustainable, scalable systems that provide high-quality, cost-effective care for populations with complex health needs.

It is in these neighborhoods where the consequences of long-standing social inequity — poverty, racism, unemployment, violence, low-grade housing, limited food access, inadequate transportation infrastructure, all urban problems — are most tightly correlated with poor health outcomes and rising costs. That must change.

Our idea is simple: cities should be healthy places to live — for everyone.

People want better health. Instead, we have traditionally given them more healthcare, under the flawed premise that providing more services automatically yields better outcomes. The difference between health (how one feels) and healthcare (what services the system provides) appears subtle, but it is critical. It underpins the contradiction of rising costs and poor health outcomes in the United States. For the individual patient, the difference between health and healthcare can be a matter of life and death. To make cities healthy, we need a system in which value is rewarded over volume, provider-patient relationships are meaningful and lasting, and the use of technology decreases costs instead of raising them.

To achieve this vision we must challenge the status quo. It is imperative that we fundamentally overhaul the system and redouble our efforts to design, test, and deploy impactful care delivery models and digital products.

How we got here

For the past 10 years, I have helped lead, design, and deploy care interventions for people frequently considered by their physicians to be the most “difficult” patients to care for: individuals with serious behavioral health challenges, physical and developmental disabilities, social needs of all kinds, and complex, chronic medical conditions.

In parallel, I saw firsthand that providers are frustrated. Clinicians find themselves increasingly pulled away from direct patient care, overwhelmed by administrative tasks, and unable to keep pace with new technology (many of these tools were primarily designed for data collection and billing — without providing obvious clinical benefit at the point-of-care). This has led to an unfortunate paradox: at the time when our communities are most in need of strong, effective healthcare leadership, our providers on the frontlines feel disengaged and alienated.

One powerful tool for driving change in healthcare are venture-backed start ups, which can have the agility to challenge long-entrenched systems. But to date, innovations entering the market largely have not met the needs of lower-income populations, instead targeting commercially-insured or Medicare populations. Billions of dollars have been invested in digital health and healthcare service transformation businesses since the passage of the Affordable Care Act. But Medicaid, despite representing more than 3 percent of the United States GDP, remains largely outside of the comfort zone of investors. And because the needs of these populations are so different, innovations in the high end of the health market cannot possibly “trickle down.” While national dialogue around Medicaid is largely about politics, there is no argument that in order to sustain this critical safety net for the long-haul, cost-effective Medicaid models are desperately needed.

That’s why we’re here.

Cityblock will provide Medicaid and lower-income Medicare beneficiaries access to high-value, readily available personalized health services. To do this, we will apply leading-edge care models that fully integrate primary care, behavioral health, and social services. And we will use our custom-built technology to enhance strong relationships between members and care teams, while simultaneously empowering and incentivizing the health system to do better.

Who we are

In founding Cityblock, I’m fortunate to be joined by an amazing group of colleagues who bring a diverse set of expertise to the table. We have brought together a dedicated, diverse crew spearheaded by Dr. Toyin Ajayi, Mat Balez, Melanie Bella, and Bay Gross. Together with our broader team, we bring deep experience launching complex care programs nationwide, building and shipping consumer tech at scale at Google, designing world-class healthcare digital products at Oscar, leading community care delivery at Mount Sinai, creating outcomes-oriented education technology at Flatiron School, and developing comprehensive state and federal policy.

Sidewalk Labs, an Alphabet company focused on accelerating urban innovation, served as the magnet that brought us together. As part of its mission to transform urban life, Sidewalk recognized the integral nature of city systems such as transportation and food access in impacting health. Cityblock’s mission to integrate healthcare and social services provided an opportunity for early fulfillment of Sidewalk’s goal of accelerating urban transformation. At Sidewalk, I was uniquely able to create an ecosystem for experts from varied backgrounds to collaborate and build solutions that no industry alone would have constructed.

Cityblock embodies the creative tension of industries colliding. We challenge each other every day to build teams, processes, and technology in ways that break the molds in which we’ve all been trained. Our technologists push our clinicians to think big, to demand digital solutions that actually meet their needs, and to build with urgency. Our clinicians remind us that without the trusted relationships between provider and patient, nothing else matters. Our community partners and Design Insights Group remind us that we don’t know all the answers: we can’t “hack” our way to understanding the day-to-day experiences of those living in the communities we’re seeking to serve. And our operators, policy-makers, and urbanist colleagues remind us that innovating in healthcare is complex — you have to navigate data privacy, payment model development, regulatory frameworks, and the politics of big systems with vested interests in the status quo. The unique lens brought by each member of our team and our partners makes Cityblock better.

What will Cityblock do?

Cityblock will partner with community-based organizations, health plans, and provider organizations to reconfigure the delivery of health and social services. We aspire to become a market-leader in value-based care for urban populations with complex health needs. We recognize the profound impact that social factors have on health, and we will reorganize the care system to directly meet the whole needs of our members.

Health is local. So we are building our company that way. We will prioritize providing care in the community, outside of hospitals and doctors’ offices whenever reasonable, and partner closely with nearby service organizations. Our care teams will forge long-term relationships with each Cityblock member and deliver high-touch care as needed, where needed, and when needed, including in-home and after-hours. We’ll put behavioral health first, breaking down long-standing silos and addressing stigma head on, recognizing that good health is often blocked by topics that we leave in the shadows. Treatment for depression, substance-use disorders, anxiety, and serious mental illness are core to our personalized system of care. We’ll also directly integrate existing community-based organizations into our service to ensure that our members’ social needs are met, ranging from transportation to connectivity, without building replacement services ourselves.

Our “clinics” — which we call Neighborhood Health Hubs — are designed as visible, physical meeting spaces where health and community converge. Caregivers, members, and local organizations will use these Hubs to engage with each other and address the many factors that affect health at the local level. Where possible, our Hubs will be built within existing, trusted spaces operated by our partners. Our workforce will be hired from the communities we serve, adding jobs and contributing to the economic well-being of the community as a whole. This approach will promote a truly collaborative, team-based environment.

To help coordinate our efforts, we’ve developed a custom-built care facilitation platform called Commons. Our platform will help care teams understand our members and the communities they reside in, build and maintain relationships at scale, work together with members toward shared goals, and drive action and accountability simultaneously — ensuring that we keep our promises. Harnessing the power of technology, with a heavy focus on design, will enable us to codify workflow, enhance communication, and over time, achieve scale.

Because this problem is urgent, we’re getting started as quickly as we can. In fact, we’ve already started. Our team is growing rapidly, with engineers, clinicians, designers, and operators coming together to hone our care model and software tools. We are working closely with prospective Cityblock members, ensuring that we are building responsibly and designing a system that meets theirneeds. Participatory design will fuel an ongoing process of co-building, iterating, and learning that is embedded in Cityblock’s DNA.

We expect to open our first Neighborhood Health Hubs in New York City in 2018, and will be looking to expand to other cities soon after. But the most exciting opportunity, we believe, is helping to support providers across the nation grappling with how to provide better care to populations with complex needs. There are millions of Americans with unmet medical and social needs today. Changes in federal and state policy have triggered a seismic shift in healthcare financing, requiring providers to develop new capabilities in order to deliver community-based, high-value care. At Cityblock, we aspire to be at the leading edge of arming the mainstream healthcare system with new tools and a new approach to caring for underserved urban populations. In many ways, this is the hardest challenge we face: how to deliver hyperlocal, personalized care at scale.

We’re not naive to the complexity ahead. We know this will be a long journey. We recognize that chronic health disparities are rooted in a deeply entrenched set of economic and social realities that span generations. We know that to have any hope of making a dent in these problems, we will need the humility to acknowledge where we are blind, the patience to stick with our members through thick and thin, a deep understanding of the hyperlocal effects that change block-by-block, and a diverse set of committed, creative people who want to make this their personal mission.

So if you’re a clinician who hopes to practice a new type of care, a technologist who wants to build digital products in service of one of the most important problems of our time, a community organizer passionate about leveraging your relationships and local knowledge for broader impact, or someone deep in traditional healthcare who knows there is a better way, we’d love to hear from you. Let’s get to work.

This article was drafted in collaboration with Dr. Toyin Ajayi, Mat Balez, Melanie Bella, and Bay Gross, with editorial support by Sara Reistad-Long and the Cityblock Health team.